Pendle Hill Center for Study and Contemplation

Religion, Justice and Health Care: The Many Connections
A Weekend with Charlene Galarneau and Suzanne SegerJanuary 19-21

Join us in exploring health care policy in the U.S. What is health? What
is caring? What actions might move us toward a more just health care community?
Charlene Galarneau teaches health care ethics and religion at Tufts University.
Suzanne Seger is a certified nurse-midwife working with immigrant communities
at Mount Sinai Medical Center.

Quote of the Week:

"Do whatever you can as well as you can do it, no matter how small."

- Mabel Dzata, midwife

The Art of Midwifery

As women approach term, tell them you expect them to eat during labor.
This is important because some women will avoid eating for fear foods
will make them nauseous. Tell them that, on the contrary, not eating will
result in hypoglycemia and increase their chances of nausea. Since most
first-time mothers have no idea what they are in for with their first
labor, I tell them to expect labor to last at least 36 hours: 24 hours
of early labor and 12 hours of more active labor. They should pace themselves
accordingly.

- Michel Odent, MD

Doula tip of the week

As part of my service I offer to write my clients a birth story. It is
not only for them, but it also serves as a way for me to journal and document.
But I found it difficult to find time to write down information. My solution
was to put rows of masking tape across my thigh, and with a pen I wear
on a cord around my neck, jot notes on the tape. This never interrupts
the laboring mom. Granted, I get funny looks at the hospital, but no funnier
than the nurses who walk around with bar code stickers on their scrubs
for labeling blood vials, etc.

News Flashes

Researchers compared family background, perinatal history
and diet of more than a hundred children with type 1 diabetes with those
of almost 500 age-matched controls. The only significant differences in
the groups were: the fathers of children with diabetes were older than
those of the controls; children with diabetes were more likely to be second-
or third-born; neonatal jaundice was more common among those with diabetes;
fewer children with diabetes went to kindergarten. There were no differences
in the duration of gestation, length of labor, delivery method, birth
weight and whether or not the infant was breastfed. Vaccination rates
were similar in both groups.

- European Journal of Pediatrics; 158:5

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Premature Rupture of Membranes (PROM)

Lenihan JP. Relationship of antepartum pelvic examinations
to premature rupture of the membranes. Obstet Gynecol 1984; 63(1): 33-37.
Women with uncomplicated pregnancies were randomly assigned to one of
two groups: weekly pelvic exams beginning at 37 weeks gestation or no
pelvic exams before 40 weeks in multipara and 41 weeks in nullipara.
Eighteen percent of those having routine pelvic exams had PROM versus
6% of those having none. The author theorizes that the probing finger
carries up and deposits on the cervix bacteria and acidic vaginal secretions
capable of penetrating the mucous plug and causing sufficient low-grade
inflammation to rupture membranes.

Women were grouped into those known to have intact membranes, those
known to have ruptured membranes either because of history and confirmation
by the attending physician or because membranes were deliberately ruptured
to induce or augment labor, or a test group of equivocal cases. The
equivocal cases were classified as ruptured or intact retrospectively
based on whether rupture was seen to occur before delivery.

High false positive rates for all three tests were found
in the women known to have intact membranes, especially in those with
copious vaginal discharge. In women with ruptured membranes, high false
negative rates were obtained for all three tests. The false negative
rate increased over time, and by 24 hours postrupture it reached 50%,
or no better than chance. Performing all three tests on multiple samples
for the test group reduced the number of incorrect results, but even
so, correct, unequivocal diagnosis was made in only 61.5% of cases.

====

If your membranes rupture on their own prior to labor, you
must believe that this is exactly the way your particular body needs
to start this particular labor. Accept it as a sign that labor will
begin sometime within the next hours or days. Stay close to home, relax,
eat well.... Increase your vitamin C and fluid intake. Before agreeing
to be induced, you can try several natural induction suggestions: visualization,
herbs, or castor oil (under the direction of a qualified midwife), for
example. Lovemaking (without sexual intercourse) and orgasm may encourage
labor to begin....

Many physicians worry that an infection will begin now that
the protection around the infant is gone. Some prescribe antibiotics
prophylactically. Others ask you to take your temperature and report
any rise. Some take blood tests to check your white blood cell count.
Most tell you that if you haven't had the baby in 12 to 24 hours, a
c-section will be performed to prevent an infection from occurring....
A cesarean to *prevent* infection? You already know the risk of infection
from cesarean section is very high. Most women can go days without an
infection after their water has broken, especially if they stay out
of the hospital and refuse internal exams. (In a single year, 1.5 million
patients were victims of hospital-acquired infections.)

E-News asked readers, "A
1996 study at the University of Toronto randomly assigned 5,041 women
with premature rupture of membranes (PROM) to either have their labors
induced or to wait for up to four days for labor to start spontaneously.
In both groups, about 3 percent of babies developed infection, and about
10 percent were delivered by cesarean section. The study concluded that
physicians should present this research to patients, who should choose
the option they prefer. Comments?

My concern is that this study disregards the effects of the induction itself and any secondary consequences as a result of interventions
arising from the induction. Measuring the outcome only by infection
and c-section rates leaves out the impact on mothers and babies of the
induction. Just because an induction doesn't necessarily result in a
c-section doesn't mean that the labor may not be more intense, more
painful, more rapid, and possibly require more pain medication than
the labors of the mothers who waited for spontaneous labor to begin.
While I am not aware of studies that have examined the short-term and
long-term effects on babies of various types of induction, anecdotal
evidence is piling up that Pitocin inductions are not benign for infants--that
certain behaviours and preferences characterize those induced with Pitocin
(among them, difficulties with transitions, need for constant stimulation
or easily over-stimulated, later addictions to caffeine and other stimulants,
ADHD-like behaviours, etc. There are certainly a few studies of the
effects of epidural anesthesia on newborns which suggest that these
babies do suffer adverse effects, so if the induced group in the above
study received more epidural anesthesia than the spontaneous labor group,
these babies may be affected by the anesthesia, and their mothers may
also have experienced consequences from the epidural.

- Claire Winstone, M.A., R.C.C.

I've had two primips and one multip whose water broke and
they wanted to wait and do nothing. Of course, they were strong, healthy,
educated women. The multip went into labor at four days; everything
was fine. Both primips ended up with c-sections. One was ruptured seven
days and the other nine. The babies and mothers were fine. Malposition
was the reason for the sections. The OB explained to me that often,
when the baby's head isn't nicely seated in the pelvis, i.e., posterior,
military, etc. the bag of waters ruptures before labor commences. You
do what you can to get the baby to adapt him/herself to the maternal
pelvis, but it doesn't always work.

- Mary Ann Durbin, CNM
Toledo, OH

I would *love* to do watchful waiting for my PROM clients.
But in this community, all the OBs and pediatricians are terrified of
GBS (we have had our share of very sick babies and babies who died),
and the CDC guidelines specify starting IV antibiotics at 18 hours.
I have no way of giving them outside the hospital. You all know what
happens when a woman is hospitalized and ruptured and not in labor.
All my clients know and are reminded that they have the right to refuse
any treatment, but I also do tell them about the CDC guidelines in order to keep the peace with the OBs who consult with me.

- Anon.

I had PROM with both of my sons. The first labor was induced
using Pitocin after waiting three hours for contractions to start. I
had a horrific, three-hour labor, which took me two years to recover
from. I researched a lot before my second, and decided on a homebirth.
With the second labor, I did not begin contractions until almost 48
hours after PROM. I had a wonderful nine-hour labor that did not leave
a mark! Not only should physicians present the research to their patients,
but the pregnant families should also. It is up to them to do what is
right for themselves and take control of "their" labors.

PROM, a Midwifery Today conference audiotape featuring Virginia
Jackson, CNM, is available from Midwifery Today for $9. Click here to find out how to order this tape and find out about other tapes
on complications of pregnancy, labor and postpartum.

Midwifery Today's Online Forums

Gestational diabetes: How many of you test for it? If you test for it, how does a positive result affect your care of the woman?
Go to our forums to share your thoughts and experience.

Question of the Week

I recently attended a birth where both the primary midwife and myself
suspected that the baby had Down syndrome because of low ears and other
facial features. How do other midwives handle situations like this? All
parents want their child to be perfect, so how do you approach this topic
in a supportive, caring and helpful manner? And what do you look for when
trying to rule out something like this? Down babies have such a distinctive
look, but what if we were wrong and caused undue stress for the parents?

Question of the Week Responses

Q: The baby of a woman who is due
in two weeks has been trembling or shivering quite hard several times
a day for a week. It lasts about a minute or at most two, and is unpredictable
as to when it occurs. She saw her OB several days ago and he has no idea
what it might be. The baby's heartbeat was in the 140s and she was not
shaking during the appointment. The OB did not seem overly concerned about
it. The mother thinks the baby is having seizures. She is certain it is
not hiccups because the baby also gets those daily and the mom can identify
them. As a doula I have worked with many women over the last 17 years
but I have never run into this. Any ideas?

- Eileen Ryan
Maryland

A: I've heard that some baby boys will shiver after urinating.

- E.W.

A: Last year I served a client (as a doula) who described similar
trembling of her unborn baby at around 30 weeks gestation. She did not
report this seizure-like trembling to her CNM until it was discovered
that her 31 week fetus was no longer living. At delivery, she had a what
seemed to be an unusually large amount of amniotic fluid (not polyhydramnios)
and the baby's two-vessel cord was wrapped very tightly around his neck.
The autopsy report was inconclusive. Shortly after this situation the
same CNM had another patient report such trembling. The midwife told her
to go immediately to the ER. An emergency c-section was performed. The
CNM said she had never learned about this seizure-like trembling nor had
she ever seen it mentioned in the medical journals she has read, but she
now takes it seriously.

- Kristin Schuchmann

A: I would recommend this woman receive a second opinion from
another OB and see a pediatrician. Pediatricians know more about unborn
babies than most people give them credit for. They will be able to give
her information about what to expect after delivery.

- R.W.

A: When I was pregnant my daughter had several "bizarre"
movement patterns I couldn't explain. One was a peculiar rhythmic fluttering
in my pelvic region. This was explained when she started sucking her wrist
after birth--the motion was her hand fluttering up and down as she suckled
on her wrist. The other was an all-over shaking too fast for hiccups.
This was explained when she abruptly went into a strange breathing pattern
after birth, in and out very, very fast with a slight noise to it for
about a minute. This only happened when she was falling asleep or had
been asleep for a while; it stopped happening within a month or so. My
daughter is now a very healthy, bright, normal, active seven-year-old.

- Jen Rosenberg CD(DONA)

A: I also had a baby who tended to do this. My midwife didn't
seem concerned, and offered no possible explanation. My baby is now thirteen
months and has never had seizures. I did notice the movements most prevalently
when I rolled over in the night, or upon just lying down. Usually it happened
when going onto my right side, and as the pregnancy went on, I felt less
comfortable on that side and uneasy about his suddenly frenetic motions,
so I avoided sleeping that way.

- Sabrina Blais, RMT/doula/aspiring midwife
Toronto, Ontario, Canada

A: The first questions I would ask is, How long does the shivering
last and how strong are they? The baby is still developing and maturing
in every way, especially neurologically. Newborn babies tend to quiver
a little when they cry, and it is attributed to their underdeveloped neurological
systems.

- Dinah, BSRN

A: [Consider] hypoglycemia or seizures. Have mother note time
of day and what she was doing. Has mother had lab work? A BMP? Also look
at magnesium levels. How well do you really know the mother? Any possibility
of substance use?

- L.B., RN

A: I felt what that mother described, during my eighth pregnancy.
I was carrying twins who were born after seven months. My doctor didn't
confirm it as a seizure. A midwife and my doctor monitored my baby (I
didn't know I was having twins until they were born) and said everything
seemed all right. I had a strong feeling that something was wrong but
couldn't bring myself to say so. Three days later I lay down to take a
nap. I felt very strong fetal movement that felt normal. The next morning
at about 3:00 am I woke up feeling impending doom. I tried to tell myself
that I was just having normal worries. Later I called the doctor and told
him I had not felt the baby move since the afternoon before. That day
an ultrasound showed that my baby no longer had a heartbeat.

One week later my girls were born. The second twin was delivered with
the placenta. When the doctor unfolded the placenta, there she was. We
could see that their umbilical cords had become entangled and caused their
deaths.

I think mothers know what their babies are doing. After my experience
if a mother were to tell me that it felt like her baby was having a seizure,
I would believe her and take it very seriously.

- K.J.

A: Several clients have reported this "shivering" during
later pregnancy. All of the babies were born uneventfully with no signs
of neurological or other problems. I think it is probably the startle
reflex happening in utero.

- Molly Germash, CPM

A: A pregnant client told me she felt restless-like movements
from her fetus. She said it was like her fetus was in a struggle. When
in labor, the fetus never descended through the pelvis. The cervix was
fully dilated but filled only with the membranes. During the cesarean
the father took photos that showed the baby's unbilical cord was wrapped
around its ankles several times with no slack at all. We concluded that
this prevented fetal descent and was also the cause for the movements
that the mother correctly described as a "struggle."

- L.B., RN

A: With my first baby I had the same feeling. He is now 10 years
old and never had any neurological problems. I have had three more pregnancies
and have never felt the seizure activity with my other babies. I have
cared for two women over the last 15 years who have had this complaint,
and had all kinds of testing. Nothing was ever found on sonos, and both
delivered healthy full-term babies. I haven't had any follow-up with either
of them to know of any long-term conditions.

- Nan, RNC

A: If the mom thinks the baby is having seizures, she should be
listened to. Even though a lot of pregnant women these days are overly
"medically dependant," most moms love their babies and want
the best for them (if they know how to get that).

- Karla

Coming E-News Themes

1.INTACT MEMBRANES: What are the fetal benefits to labor with intact
membranes? Do you have any documentation to share with E-News readers?

QUESTION OF THE QUARTER for Midwifery Today magazine

Switchboard

Know a strong woman? Helping empower one? If you haven't already done so, please forward this issue of Midwifery Today E-News to one or two of your friends or business associates. Thanks so much!

More on vitamin K:

Could you explain more about why you state that HDN is virtually untreatable
[Issue 2:45]? I have a packet of vitamin K information I give to mothers,
and have tried to fairly represent both sides of the issue. A couple of the studies I have included (which support vit. K administration) say
that the treatment for HDN is IV infusion of vit. K, which would arrest
the problem within two hours. It did not sound as if there was great risk
of adverse sequelae unless the disease had continued for some time without
being recognized.

- Janelle Wahlman, CN

Three years ago I attended a mother who delivered her beautiful 7-lb.
baby boy (her second) at home with no complications of any kind. The parents
refused eye ointment and vitamin K after doing their own research as well
as reading and discussing materials I routinely include in the homebirth
packet I give to all my clients. They based their decision to refuse these
things mostly on statistical evidence that shows that problems are actually
fairly rare, and they strongly didn't want to expose their new baby to
anything that would make him unnecessarily uncomfortable for the sake
of prophylaxis. Unfortunately the baby developed hemorrhagic disease of the newborn (HDN) the next day. His bleeding sites were gastrointestinal
and nasal. He was hospitalized and treated for four days and made a complete
recovery. Although this has been the only case of HDN I have seen in my
clients who have refused prophylactic vitamin K , it was traumatic enough
to induce me to highly recommend it to my clients. The parents of the
baby that developed HDN are dealing with guilt and regret because they
feel that though the incidence is rare, their child ended up suffering
and the prevention (an injection) was readily available and would have
been much more noninvasive than what their little guy had to go through.

- Alda Bales

I was dismayed to read the submission from C.R. regarding four babies
dying from hemmorhagic disease of the newborn because of no vit K shot.
This is anecdotal and worse, anonymous. It scares the pants off people
and is not true. I live in Canada and make it my business to know what
happens at homebirths right across Canada. I would challenge C.R. to come
up with cities, dates and citations before putting out this kind of bogus
claim.

- Gloria Lemay
Vancouver, BC

More on urinary retention:

Provided that all the possibilities have been ruled out, such as structural
problems (cystocele, urethrocele, narrow bladder neck, etc.) including
a previous history of bladder problems even when not pregnant, the problem
may be hormonal due to an insufficient level of progesterone to support
the smooth muscles (e.g. the bladder and urethra). We know that after
conception the natural progesterone level rises considerably but that
in some women it may not rise quickly enough to meet the need before the
12th week when the placenta is developed and then takes over the production
of progesterone for the remainder of the pregnancy. Some women exhibit
symptoms of low progesterone in early pregnancy with extreme nausea and
vomiting and some women will bleed or in some cases will miscarry. One
of the symptoms of low progesterone, pregnant or not, is the problem of
a spastic bladder, which encourages urinary retention which then leads
to a "set-up" for an infection.

Based on the information provided in your inquiry, it sounds like the
same phenomenon of low progesterone occurs in your ninth month. We do
know that near term the placental production of hormones is decreased
and the symptoms are most commonly insomnia, hot flashes, diminished appetite,
sometimes even a loss in a little weight, increased uterine activity (hint:
the uterus is a smooth muscle just like the bladder and urethra and all
smooth muscle has the potential to react symptomatically to a drop in
progesterone). We also can notice a change in attitude and moods just
like in PMS which, by the way, is also proven to be related to an inadequate
production of progesterone during the luteal phase.

I would recommend that you get Dr. John Lee's book What Your Doctor May
Not Be Telling You About Menopause.

Logical treatment or prevention may be to use evening primrose oil, chamomile
and the appropriate dose of vitamin C, drink a lot of fluid, watch for
signs of infection and take antibiotics only if necessary and use a catheter
only if necessary.

- Marcia McCulley, NP

The mother's bladder may have become detached or out of place or changes
place with the colon. Lying on a slant board with head down may relieve
this problem. It may allow the organs to resume their proper position.
If the problem is caused because there are stones in the bladder, an herbal
kidney cleanse may help. Herbs such as uva ursi, cranberry, and parsley
have been used traditionally to alleviate discomfort due to blockage.
If this doesn't work, it might be time for a checkup by a specialist to
see what the problem really is.

- Robe

====

What a shock to read of MANA's proposal to exclude some members! [Issue
2:45] It makes me think of the medical profession, which systematically
worked to exclude midwives, naturopaths, homeopaths, chiropractors and
any other healing modality at the beginning of the 1900s. The Midwives
of North America (MANA) folks seem to be following the example set by
medical practice. How arrogant. How righteous. How stupid.

Birth by any sort of midwife is under attack right now in the USA. Right
now, for example, in Pennsylvania, the AMA is working to further restrict
CNM practice. So what are we doing to ourselves, by dividing our energies
still further and pointing fingers at each other because some people have
initials after their names and some don't? What are we thinking of, to
even consider such a thing when the trend in mainstream obstetrical practice
is toward elective cesareans, more inductions and increased epidural use?
Initials are no guarantee of good practice--never have been, never will
be. This is true in breastfeeding circles as well as birthing circles
and with lawyers as well as with teachers. So let that struggle go.

My prayer is that all the birthing folks (including doulas and childbirth
educators) and all the breastfeeding folks unite and take back birth.
Those working with mothers and babies before birth need to join forces
with all those working with mothers and babies after birth to turn back
the technological tide. The only way we can do that is together.

- Nikki Lee RN, MSN, Mother of 2, IBCLC, CIMI
Elkins Park, PA

A simple thought: As regards MANA's decision to become so exclusive,
I think all American midwives need to reread George Orwell's book, Animal
Farm! This kind of exclusivity comes from wanting to be accepted and fit
in with the oppressor (the medical profession) or a desire for greater
power and/or profits. The same pattern has been seen all over the world
when people give in to the pressures of commercialism and imperialism.
Instead of sharing, someone has to be squeezed out so others can get more.
And it's usually the majority who are sacrificed to benefit a few. Please
think very carefully about this decision!

- Harriet Kaufman RN MSN, midwife

====

This is just to say hello and thanks for E-News every week. All your
comments are so important. I am an occupational therapist who has offered
prenatal courses in Monteria, Colombia for 11 years. I feel worried about
why doctors don't want women to have vaginal births. Every day we see
more cesareans.

- Carolina

====

In response to Anon's comment on doulas [Issue 2:45]: You ask
why a woman would birth in a place where she needs an advocate. I think
you are assuming a lot by believing that every woman has a choice. Many
women birth in hospitals by necessity for the health of themselves, their
baby, or both.

I am an RN working in a hospital setting who used to work as a doula.
I aspire to be a midwife, but I struggle with choosing the best route
to take based on where I will be most helpful. I agree that sometimes
hospital birth can be abusive and that many women are way too complacent
and relinquish control. But I have no shame in being a part of it. I am
here to be an advocate for those women. In fact, I find strength in helping
women get through their birth experience regardless how it turns out,
and to hopefully be able to provide them with what they need to make informed
choices. I also think it is healthy to acknowledge the loss of the "perfect
birth" and allow a woman to mourn that loss. But I by no means pass
judgment on that woman's decisions.

Frankly, your comments make me question whose expectations are being
disappointed more, yours or the mother's? It is sad when we feel disempowered
by our environment rather than seeing our need and ability to empower
a mother in that environment. Please, don't turn your back on hospital
birth. Instead, be an agent for change.

- Luisa Lucero, RN

====

My sister is in her ninth month with her third child and her cervix seems
to be "falling out." Her doctors tell her it is because it is
her third pregnancy and because the baby is pushing down on her cervix.
Is this going to cause problems for her during and after delivery? What
causes it? Also, how long after losing the mucous plug do women usually
deliver? My sister has been losing her plug for several days and nothing
seems to be happening.

I am a third-year student midwife in the UK, about to qualify and writing
my dissertation about how best to care for women whose babies present
by the breech. Does anyone out there have any personal clinical experience
or better yet, audit information on standing breech births under the care
of midwives? I badly need your input to counter the arguments in the recently
published paper by Hannah et al. in the Lancet.

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